Health Assessment FINALS Reviewer 1

UNIT 5A: Physical Assessment
A. Skin, Hair and Nails

B. Head and Neck
C. Eyes
D. Ears
E. Mouth, Throat, Nose, and Sinuses
● Review of Anatomy and Physiology
● Equipment Used
● Examination (IPPA)
● Abnormal/Significant Findings
A. Skin, Hair, and Nails Assessment

A. Review of Anatomy and Physiology
The skin, hair, and nails are external structures that serve a variety of specialized functions. The
sebaceous and sweat glands originating within the skin also have many vital functions.
SKIN
● composed of three layers: the epidermis, dermis, and subcutaneous tissue
● physical barrier that protects the underlying tissues and structures from microorganisms, physical
trauma, ultraviolet radiation, and dehydration.
● It plays a vital role in temperature maintenance, fluid and electrolyte balance, absorption,
● excretion, sensation, immunity, and vitamin D synthesis:
● provides an individual identity to a person's appearance.
Epidermis
● the outer layer of skin, is composed of four distinct layers:
● the stratum corneum, stratum lucidum, stratum granulosum, and stratum germinativum.
Dermis
● The inner layer of skin is the dermis. It is connected to the epidermis by means of papillae.
● a well-vascularized connective tissue layer containing collagen and elastic fibers, nerve endings, and
lymph vessels.
● the origin of hair follicles, sebaceous glands, and sweat glands.
Sebaceous Glands
● Develop from hair follicles and are present over most of the body, excluding the soles and palms
Secrete an oily substance called sebum that lubricates hair and skin and reduces water loss through
the skin.
● Sebum also has some fungicidal and bactericidal effects.
Sweat Glands
● The eccrine glands are located over the entire skin surface and secrete an odorless, colorless fluid, the
evaporation of which is vital to the regulation of body temperature.
● The apocrine glands are concentrated in the axillae, perineum, and areolae of the breast and are
usually open through a hair follicle. They secrete a milky sweat. The interaction of sweat with skin
bacteria produces a characteristic body odor
Subcutaneous Tissue
● is a loose connective tissue containing fat cells, blood vessels, nerves, and the remaining portions of
sweat glands and hair follicles.
● assists with heat regulation
● contains the vascular pathways for the supply of nutrients and removal of waste products from the skin.
HAIR
● consists of layers of keratinized cells
● found over much of the body except for the lips, nipples, soles of the feet, palms of the hands, labia
minora, and penis.
● develops within a sheath of epidermal cells called the hair follicle
B. Equipment Used for EXAMINATION OF THE SKIN

● Examination light
● Penlight
● Mirror for client's self-examination of skin
● Magnifying glass
● Centimeter ruler
● Gloves
C. Examination and Findings

Inspection
Inspect general skin coloration
Normal Findings Abnormal Findings
● evenly colored skin tones without ● Pallor (loss of color) is seen in arterial
unusual or prominent discolorations. insufficiency, decreased blood supply, and
● small amounts of melanin are common in anemia.
whiter skins, while large amounts of melanin
are common in olive and darker skins.
Carotene accounts for a yellow cast.
● the older client's skin becomes pale due to
decreased melanin production.
● While inspecting skin coloration, note any
odors emanating from the skin. Client has
slight or no odor of perspiration, depending
on activity.
● Cyanosis may cause white skin to appear

blue-tinged, especially in the perioral, nailbed,
and conjunctival areas. Dark skin may appear
blue, dull and lifeless in the same areas.
Abnormal Findings Illustrations
Jaundice
● in light- and dark-skinned people is
characterized by yellow skin tones, from pale
to pumpkin, particularly in the sclera, oral
mucosa, palms, and soles.
Acanthosis nigricans
● is roughening and darkening of skin in

localized areas, especially the posterior neck.
Strong Odor
● A strong odor of perspiration or foul odor may

indicate disorder of sweat glands.
● Poor hygiene practices may indicate a need
for client teaching or assistance with activities
of daily living.
Inspection
Inspect for color variations. Inspect localized parts of the body, noting any color variation
● some clients have sun-tanned areas, include rashes, such as the reddish (in light-skinned
freckles, or white patches known as vitiligo people) or darkened (in dark-skinned people)
● The variations are due to different amounts of butterfly rash across the bridge of the nose and
melanin in certain areas. Dark-skinned clients cheeks,red
have lighter-colored palms, soles, nailbeds,
and lips.
● Frecklelike or dark streaks of pigmentation
are also common in the sclera and nailbeds
of dark-skinned clients. Albinism is a generalized loss of pigmentation.
● White-skinned clients have darker pigment
around nipples, lips, and genitalia.
Erythema (skin redness and warmth) is seen in

inflammation, allergic reactions, or trauma.
Check skin integrity, especially carefully in pressure point areas.

● Skin is intact, and there are no reddened ● Skin breakdown is initially noted as a
areas. reddened area on the skin that may progress
to serious and painful pressure ulcers
Inspect for lesions. Observe the skin surface to detect abnormalities. Note color, shape, and size of lesion. For
very small lesions, use a magnifying glass to note these characteristics.
● Smooth, without lesions. Stretch marks ● Lesions may indicate local or systemic
(striae), healed scars, freckles, moles, or problems.
birthmarks are common findings. ● Primary lesions arise from normal skin due to
● Lesion does not fluoresce. irritation or disease.
● Secondary lesions arise from changes in
primary lesions. Vascular lesions,
reddish-bluish lesions, are seen with
bleeding, venous pressure, aging, liver,
disease or pregnancy.
Palpation
Palpate skin to assess texture. Use the palmar surface of your three middle fingers to palpate skin texture
● Skin is smooth and even. ● Rough, flaky, dry skin is seen in

hypothyroidism. Obese clients often report
dry, itchy skin.
Palpate to assess thickness. If lesions are noted when assessing skin thickness, put gloves on and palpate
the lesion between the thumb and finger. Observe for drainage or other characteristics
● Skin is normally thin but calluses (rough, thick ● Very thin skin may be seen in clients with
sections of epidermis) are common on areas arterial insufficiency or in those on steroid
of the body that are exposed to constant therapy
pressure.
Palpate to assess moisture. Check under skin folds and in unexposed areas
● Skin surfaces vary from moist to dry ● Increased moisture or diaphoresis (profuse
depending on the area assessed. Recent sweating).
activity or a warm environment may cause ● Decreased moisture (dehydration)
increased moisture. ● Clammy skin (shock or hypotension)
Palpate to assess temperature. Use the dorsal surfaces of your hands to palpate the skin
● Skin is normally a warm temperature ● Cold skin (shock or hypotension)

● Cool skin (arterial disease)
● Very warm skin (febrile state or
hyperthyroidism)
Palpate to assess mobility and turgor.

● Skin pinches easily and immediately returns ● Decreased mobility is seen with edema.
to its original position. ● Decreased turgor (a slow return of the skin to
its normal state taking longer than 30
seconds) is seen in dehydration.
Palpate to detect edema. Use your thumbs to press down on the skin of the feet or ankles to check for edema
● Skin rebounds and does not remain indented ● Indentations on the skin may vary from slight
when pressure is released. to great and may be in one area or all over
the body.
SCALP AND HAIR
Inspection and Palpation
Have the client remove any hair clips, hair pins, or wigs. Then inspect the scalp and hair for general color and
condition.
● Natural hair color ● Nutritional deficiencies may cause patchy

● The color is determined by the amount of gray hair in some clients.
melanin present. ● copper-red hair color (Severe
● Scalp is clean and dry. ● malnutrition)
● Sparse dandruff may be visible. ● Excessive scaliness (dermatitis)
● Hair is smooth and firm, somewhat ● Raised lesions (infections or tumor growth)
● elastic. hair feels coarser and drier (older ● Dull, dry hair (hypothyroidism and
people) amount and distribution of scalp, malnutrition)
body, axillae, and pubic hair. ● Pustules with hair loss in patches are seen in
● Fine vellus hair covers the entire body except tinea capitis
for the soles, palms, lips, and nipples. ● Infections of the hair follicle folliculitis) appear
● Normal male pattern balding is symmetric as pustules surrounded by erythema.
● Excessive generalized hair loss
● Patchy hair loss (infection SLE,
chemotherapy)
NAILS
Inspect nail grooming and cleanliness, nail color and marking, shape of nails
NAILS
Inspect nail grooming and cleanliness, nail color and marking, shape of nails
● Nails are clean and manicured. ● Dirty, broken, or jagged fingernails (poor
● Pink tones should be seen. Some longitudinal hygiene)
ridging is normal. ● Pale or cyanotic nails (hypoxia or anemia)
● There is normally a 160-degree angle ● Splinter hemorrhages (trauma) Beau's lines
between the nail base and the skin. (acute illness)
● Yellow discoloration (fungal infections or
psoriasis)
● Nail pitting (psoriasis) Early clubbing
(180-degree angle with spongy sensation)
● late clubbing (greater than 180-degree
angle)>>>hypoxia.
● Spoon nails (concave) >>>iron deficiency
anemia
Palpate nail to assess texture, consistency, noting whether nail plate is attached to nailbed. Test capillary
refill in nailbeds by pressing the nail tip briefly and watching for color change
● Nails are hard and basically immobile. ● Thickened nails especially toenails
● smooth and firm; nailplate should be firmly (decreased circulation)
attached to nailbed. ● Paronychia (inflammation) indicates local
● Pink tone returns immediately to blanched infection.
nailbeds when pressure is released. ● Onycholysis- detachment of nailplate
● from nailbed (infections or trauma) There is
slow (greater than 2 seconds) capillary
nailbed refill (return of pink tone) with
respiratory or cardiovascular diseases that
cause hypoxia.
B. Head and Neck Assessment
Head and neck assessment focuses on the cranium, face, thyroid gland, and lymph node structures contained
within the head and neck.
Cranium
● houses and protects the brain and major sensory organs.
● It consists of eight bones: Frontal (1) Parietal (2) Temporal (2) Occipital (1) Ethmoid (1). Sphenoid (1)
● In the adult client, the cranial bones are joined together by immovable sutures: the sagittal, coronal,
squamosal and lambdoid sutures.
Face
● Facial bones give shape to the face. The face consists of 14 bones: Maxilla (2) Zygomatic (cheek)
● (2) Inferior conchae (2) Nasal (2) Lacrimal (2) Palatine (2) Vomer (1) Mandible (jaw) (1)
Muscles and Cervical Vertebrae
● Sternomastoid (sternocleidomastoid/SCM) and trapezius muscles are two of the paired muscles that
allow movement and provide support to the head and neck.
● SCM rotates and flexes the head, whereas the trapezius muscle extends the head and moves the
shoulders.
● The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders
by the trapezius muscles and turning the head against resistance by the sternomastoid muscles.
Blood Vessels
● The internal jugular veins and carotid arteries are located bilaterally, parallel and anterior to the
sternomastoid muscles..
● The external jugular vein lies diagonally over the surface of these muscles.
However, you need to know the location of the carotid arteries when assessing the neck to avoid bilateral
compression of the vessels, which can reduce the blood supply to the brain.
Thyroid Gland
● the largest endocrine gland in the body.
● produces thyroid hormones that increase the metabolic rate of most body cells.
LYMPH NODES OF THE HEAD AND NECK

● filter lymph, a clear substance composed mostly of excess tissue fluid, after the lymphatic vessels
● collect it but before it returns to the vascular system.
● This filtering action removes bacteria and tumor cells from lymph.
The most common head and neck lymph nodes are referred to as follows:
● Preauricular
● Postauricular
● Tonsillar
● Occipital
● Submandibular
● Submental
● Superficial cervical
● Posterior cervical
● Deep cervical
● Supraclavicular
EQUIPMENT BEING USED:

● Gloves
● Cup of water
● Stethoscope

Inspect the head. Inspect for size, shape, configuration, and involuntary movement.
head is symmetric, round, erect, and in midline. Acromegaly- skull and facial bones are larger and
thicker, increase prdxn of GH
No lesions are visible.
Acorn-shaped (Paget's disease)
should be held still and upright
horizontal jerking movement (neurologic disorders)
An involuntary nodding movement (aortic

insufficiency)
Head tilted to one side (unilateral vision/ hearing

deficiency or shortening of SCM
Palpate the head. Palpate for consistency

normally hard and smooth without lesions. Lesions or lumps on the head may indicate recent
trauma or cancer.
Inspect the face, inspect for symmetry, features, movement, expression, and skin condition.
symmetric with a round, oval, elongated, or square ● Asymmetry in front of the earlobes (parotid
appearance. gland enlargement)
● Unusual or asymmetric orofacial movements
No abnormal movements noted. (organic disease or neurologic problem)
● Drooping of one side of the face (stroke, CVA,
facial wrinkles (older clients) Bell's palsy)
● "mask like" face (Parkinson’s disease)
● cachexia (emaciation or wasting)- "sunken
face with depressed eyes and hollow cheeks
● pale, swollen face nephrotic syndrome)
Palpate the temporal artery, which is located between the top of the ear and the eye
The temporal artery is elastic and not tender. hard, thick, and tender with
inflammation---temporal arteritis (inflammation of the
temporal arteries that may lead to blindness).
Palpate the temporomandibular joint. To assess the temporomandibular joint (TMJ), place your index finger
over the front of each ear as you ask the client to open her mouth
● No swelling, tenderness, or crepitation with ● Limited ROM, swelling, tenderness, or

movement. crepitation (TMJ syndrome)
● Mouth opens and closes fully (3 to 6 cm
between upper and lower teeth).
● Lower jaw moves laterally 1 to 2 cm in each
direction.
Inspect the neck.
● Observe the client's slightly extended neck for position, symmetry, and lumps or masses.
● Any swelling, movement of the neck structures. Observe the movement of the thyroid cartilage, thyroid
gland while swallowing.
● Inspect the cervical vertebrae and range of motion. Ask the client to flex the neck.
● Neck is symmetric with head centered and ● Swelling, enlarged masses, or nodules may
without bulging masses. indicate an enlarged thyroid gland,
● The thyroid cartilage, cricoid cartilage, and Inflammation of lymph nodes, or a tumor
thyroid gland move upward symmetrically as Asymmetric movement or generalized
the client swallows. enlargement of the thyroid gland
● C7 (vertebrae prominens) is usually visible ● Prominence or swellings other than the C7
and palpable. vertebrae may be abnormal.
● Neck movement should be smooth and ● Muscle spasms, inflammation, or cervical
controlled with 45-degree flexion, 55- degree arthritis may cause stiffness, rigidity, and
extension, 40-degree lateral abduction, and limited mobility of the neck.
70-degree rotation.
Palpation
● Palpate the trachea. Place your finger in the sternal notch. Feel each side of the notch and palpate the
tracheal rings.
● Palpate the thyroid gland. Locate key landmarks with your index finger and thumb: Hyoid bone; Thyroid
cartilage; Cricoid cartilage
● Trachea is midline. Landmarks are positioned ● trachea may be pulled to one side in cases of
midline. a tumor, thyroid gland enlargement, aortic
aneurysm, pneumothorax, atelectasis, or
fibrosis.
● Landmarks deviate from midline or are
obscured because of masses or abnormal
growths.
Auscultation
Auscultate the thyroid only if you find an enlarged thyroid gland during inspection or palpation
● No bruits are auscultated ● A soft, blowing, swishing sound auscultated

over the thyroid lobes (hyperthyroidism)
Lymph Nodes of the Head and Neck

● Palpate the preauricular nodes
● postauricular nodes
● occipital nodes Palpate the tonsillar nodes
● Palpate the submandibular nodes
● Palpate the submental node
● Palpate the superficial cervical nodes
● Palpate the posterior cervical nodes
● Palpate the deep cervical chain nodes
● Palpate the supraclavicular nodes
No swelling or enlargement, no tenderness, no Enlarged nodes are abnormal.

hardness is present. Swelling, tenderness, hardness, immobility are
abnormal.
C. Eyes Assessment
● Eye - transmits visual stimuli to the brain for interpretation functions as the organ of vision.
● The eyeball is located in the eye orbit, a round, bony hollow formed by several different bones of the
skull. In the orbit, the eye is surrounded by a cushion of fat. The bony orbit and fat cushion protect the
eyeball.
The external layer consists of the sclera and cornea.
Sclera
dense, protective, white covering
physically supports the internal structures of the
eye window of the eye"
Cornea
permits the entrance of light, w/c passes
through the lens to the retina.
The middle layer contains both an anterior

portion (iris and the ciliary body), and
posterior layer (chorold).
The innermost layer, the retina, extends only to

the ciliary body anteriorly.
Visual Fields and Visual Pathways

A visual field refers to what a person sees with one eye.
The visual field of each eye can be divided into four quadrants:
upper temporal, lower temporal, upper nasal, and lower nasal
Visual Reflexes
Pupillary light reflex
● causes pupils immediately to constrict when
exposed to bright light.
● direct reflex-constriction occurs in the eye exposed
to the light
● indirect or consensual reflex-exposure to light in
one eye results in constriction of the pupil in the
opposite eye.
● mediated by the oculomotor nerve
Accommodation
● is a functional reflex allowing the eyes to focus on
near objects.
● is accomplished through movement of the ciliary
muscles causing an increase in the curvature of the
lens.
B. Equipment Used
● Snellen or E chart
● Hand-held Snellen card or near vision screener
● Penlight
● Opaque cards
●
● Ophthalmoscope
● Disposable gloves (wear as needed to prevent spreading infection or coming in contact with exudate)

Test distant visual acuity.
Normal distant visual acuity is 20/20 with or without ● Myopia (impaired far vision) is present when
corrective lenses. This means the client can the second number in the test result is larger
distinguish what the person with normal vision can than the first (20/40).
distinguish from 20 feet away. ● The higher the second number, the poorer
the vision.
● A client is considered legally blind when
vision in the better eye with corrective lenses
is 20/200 or less.
Test near visual acuity.

● Normal near visual acuity is 14/14 (with or ● Presbyopia (impaired near vision) is indicated
without corrective lenses). when the client moves the chart away from
● Client can read what the normal eye can read the eyes to focus on the print.
from a distance of 14 inches. ● It is caused by decreased accommodation.
Test visual fields for gross peripheral vision

● With normal peripheral vision, the client A delayed or absent perception of the examiner’s
should see the examiner's finger at the same finger indicates reduced peripheral vision
time the examiner sees it.
● Normal visual field degrees are approximately

as follows:
○ Inferior: 70 degrees
○ Superior: 50 degrees
○ Temporal: 90 degrees
○ Nasal: 60 degrees
Testing Extraocular Muscle Function

Perform corneal light reflex test.
The reflection of light on the corneas should be in the ● Asymmetric position of the light reflex
exact same spot on each eye, which indicates indicates deviated alignment of the eyes.
parallel alignment. ● Due to muscle weakness or paralysis
Perform cover test.

● The uncovered eye should remain fixed ● Phoria - misalignment that occurs only when
straight ahead. fusion reflex is blocked.
● The covered eye should remain fixed straight ● Strabismus - constant malalignment of the
ahead after being uncovered. eyes.
● Tropia is a specific type of misalignment:
○ esotropia is an inward turn of the eye
○ exotropia is an outward turn of the
eye.
Eye movement should be smooth and symmetric ● weakness in one or more extraocular
throughout all six directions. muscles or dysfunction of the cranial nerve
● Nystagmus, an oscillating (shaking)-

movement of the eye

Inspect the eyelids and eyelashes. Note width and position of palpebral fissures.
Assess the ability of eyelids to close. Note the position of the eyelids in comparison with the eyeballs. Also note
any unusual Turnings Color Swelling Lesions. Discharge
● the upper lid margin should be between the ● Ptosis, drooping of the upper lid
upper margin of the iris and the upper margin ● Myasthenia gravis, weakened muscle or
of the pupil. the lower lid margin rests on the tissue
lower border of the iris. ● Retracted lid margins (hyperthyroidism)
● No white sclera is seen above or below the ● Corneal damage-failure of lids to close
iris. completely puts client
● Palpebral fissures may be horizontal. ● Entropion-inverted lower lid
● The upper and lower lids close easily and ● Ectropion-an everted lower eyelid.
meet completely when closed. The lower
eyelid is upright with no inward or outward
turning.
● Eyelashes are evenly distributed and curve
outward along the lid margins.
● Xanthelasma, raised yellow plaques located
most often near the inner canthus
Observe redness, swelling, discharge. Or lesions.

Observe the position and alignment of the eyeball in the eye socket.
● Skin on both eyelids is without redness, ● Seborrhea or blepharitis- Redness and

swelling, or lesions. crusting along the lid margins.
● Eyeballs are symmetrically aligned insockets ● Hordeolum (stye), a hair follicle infection,
without protruding or sinking. causes local redness, swelling, and pain.
● Chalazion, an infection of the meibomian
gland- extreme swelling of the lid, moderate
redness, but minimal pain
● Exophthalmos- Protrusion of the eyeballs
accompanied by retracted eyelid (Graves'
disease)
● sunken appearance of the eyes (severe
dehydration or chronic wasting illnesses)
Inspect the bulbar conjunctiva and sclera

● Clear, moist, and smooth ● conjunctivitis (pink eye).

● Sclera is white ● Areas of dryness (allergies or trauma)
● Episcleritis - local, noninfectious inflammation
of the sclera.
Inspect the palpebral conjunctiva

● lower and upper palpebral conjunctivae are ● Cyanosis of the lower lid (heart or lung
clear and free of swelling or lesions. disorder)
● Palpebral conjunctiva is free of swelling, ● A foreign body or lesion may cause irritation,
foreign bodies, or trauma. burning, pain and/or swelling of the upper
eyelid.
Inspect and palpate the lacrimal apparatus.

● No swelling or redness should appear over ● Swelling of the lacrimal gland; Redness or
areas of the lacrimal gland. swelling around the puncta (infection, or an
● The puncta is visible without swelling or inflammatory condition)
redness and is turned slightly toward the eye. ● Excessive tearing (nasolacrimal sac
● No drainage obstruction)
● Expressed drainage from the puncta (duct
blockage)"
Inspect the cornea and lens

● transparent with no opacities. ● Areas of roughness or dryness (injury or

● the oblique view shows a smooth and overall allergic responses)
moist surface; ● Opacities of the lens are (cataracts)
● the lens is free of opacities.
Inspect the iris and pupil

● Iris :round, flat, and evenly colored. ● irregularly shaped irises, miosis, mydriasis,
● The pupil, round with a regular border, is and anisocoria.
centered in the iris. ● If the difference in pupil size changes
● Pupils are normally equal in size (3 to 5 mm). ● throughout pupillary response tests, the
● An inequality in pupil size of less than 0.5 mm ● inequality of size is abnormal.
occurs in 20% of clients. This condition,
called anisocoria, is normal.
Test pupillary reaction to light
● normal direct pupillary response is ● Monocular blindness -no response in either

constriction. pupil.
● normal consensual pupillary response is ● When light is directed into the unaffected eye,
constriction. both pupils constrict.
● Pupils do not react at all to direct and
consensual pupillary testing.
Test accommodation of pupils

The normal pupillary response is constriction of the ● Pupils do not constrict

pupils and convergence of the eyes when focusing ● Eyes do not converge.
on a near object (accommodation and convergence).
D. Ears Assessment
● Ears - sense organ of hearing and equilibrium.
● It consists of three distinct parts: the external ear, the middle ear, and the inner ear.
● The tympanic membrane separates the external ear from the middle ear.
● Middle and inner ear cannot be directly inspected. Instead, these parts of the ear are assessed by
testing hearing acuity and the conduction of sound.
B. Equipment Used
● Watch with a second-hand for Romberg test
● Tuning fork (512 or 1, 024 Hz)
● Otoscope

Inspect the auricle, tragus, and lobule. Note size, shape and position.
● Ears are equal in size bilaterally (normally 4 ● Malaligned or low-set ears (genitourinary
to 10 cm). disorders or chromosomal defects)
● The auricle aligns with the corner of each eye
and within a 10-degree angle of the vertical ● Enlarged preauricular and postauricular
position. lymph nodes-infection
● Earlobes may be free, attached, or soldered ● Tophi (nontender, hard, cream-colored
(tightly attached to adjacent skin with no nodules on the helix or antihelix,
apparent lobe). con_x0002_taining uric acid crystals)-gout
● skin is smooth with no lesions, lumps, or ● Blocked sebaceous glands- postauricular
nodules. cysts
● Color is consistent with facial color. ● Ulcerated, crusted nodules that bleed - skin
● Darwin's tubercle, which is a clinically cancer
insignificant projection, may be seen on the ● Redness, swelling, scaling, or itching otitis
auricle externa
● No discharge should be present. ● Pale blue ear color-frostbite
Palpate the auricle and mastoid process
● Auricle, tragus, and mastoid process are not ● A painful auricle or tragus is associated with
tender otitis externa or a postauricular cyst.
● Tenderness over the mastoid process

(mastoiditis)
● Tenderness behind the ear may occur

(otitis media).
Perform Weber’s Test if the client reports diminished or lost hearing in one ear.
● Vibrations are heard equally well in both ears. ● With conductive hearing loss, the client
No lateralization of sound to either ear. reports lateralization of sound to the poor
ear-that is, the client "hears" the sounds in
the poor ear. The good ear is distracted by
background noise, conducted air, which the
poor ear has trouble hearing. Thus the poor
ear receives most of the sound conducted by
bone vibration.
● With sensorineural hearing loss, the client

reports lateralization of sound to the good
ear. This is because of limited perception of
the sound due to nerve damage in the bad
ear, making sound seem louder in the
unaffected ear.
MODULE 5: Unit 5B: PHYSICAL ● An S3 sound (ventricular gallop) indicates
rapid ventricular filling and can be an
ASSESSMENT
expected finding in children and young
(Heart and Neck Vessels)
adults. Use the bell of the stethoscope.
● An S4 sound reflects a strong atrial
Why is cardiac assessment important? contraction and can be an expected
Heart and Neck Vessels finding in older and athletic adults and
● There are landmarks on the chest wall that children. Use the bell of the stethoscope.
will yield Important information about the
function of the heart and its valves. Cardiac Cycle and Heart Sounds
● Angle of Luis - located 1 inch below the ● Dysrhythmias occur when the heart fails to
sternal notch where the manubrium and beat at regular successive intervals.
the body of the sternum are joined. ● Gallops are extra heart sounds. Use the
○ The 2nd ribs extend to the right bell of the stethoscope.
and left of this angle. ○ Ventricular gallop occurs after
○ Once the 2nd rib is located, S2, sounds like Ken-tuck'-y
palpate downward and obliquely ○ Atrial gallop occurs before S1,
away from the sternum to identify sounds like "Ten'-es-see"
the remaining ribs and Intercostal
spaces.
Murmurs are audible when blood volume in
Equipments:
the heart increases or its flow is impeded or
● Stethoscope with bell and diaphragm
altered. Use the bell of the stethoscope to hear
● Small pillow
the characteristic blowing or swishing sound. Can
● Penlight or movable examination light
be asymptomatic or a finding of heart disease.
● Watch with second hand
● Systolic murmurs occur just after S1
● Centimeter ruler (2)
● Diastolic murmurs occur just after S2.
Other terms used to document Cardiac Cycle and Heart Sounds

● Thrills are a palpable vibration that can
locations for chest physical
accompany murmurs or cardiac
assessment include malformation.
● Supraclavicular - above the clavicles ● Bruits are blowing or swishing sounds
● Infraclavicular - below the clavicles that indicate obstructed peripheral blood
● Interscapular- between the scapulae flow. Use the bell of the stethoscope.
● Infrascapular- below the scapulae Bases
of the lungs the lowermost portions
● Upper, middle, and lower lung fields
Auscultatory Sites for the Heart
● Aortic: Just right of the sternum at the
second ICS
● Pulmonic: Just left of the sternum at the
Cardiac Cycle and Heart Sounds second ICS
● Closure of the mitral and tricuspid valves ● Erb's point: Just left of the sternum at the
signals the beginning of ventricular systole third ICS
(contraction) and produces the S1 sound ● Tricuspid: Just left of the sternum at the
(lub). Place the diaphragm of the fourth ICS
stethoscope at the apex. ● Apical/mitral: Left midclavicular line at
● Closure of the aortic and pulmonic valves the fifth ICS
signals the beginning of ventricular
diastole (relaxation) and produces the S2
sound (dub). Place the diaphragm of the
stethoscope at the aortic area.
● Are you familiar with the risk factors for
heart disease?
● Does anyone in your family have health
problems related to the heart?
INSPECTION
Heart
● Observe the precaution for any bulging,
heaving or thrusting.
● Look for the point of maximum impulse
(PMI) or apical pulse at the left,
midclavicular, 5th intercostal space.
● Note any other pulsations on the chest.
Normal Findings
● No bulges on the chest.
● An apical impulse may or may not be
observable.
HEALTH HISTORY: REVIEW OF ● There should be no other pulsations
SYSTEMS (Questions to Ask) over the chest, aside from the apical
● Do you have any problems with your impulse.
heart? Do you take any medications for
your heart?
● Have you had any history of heart trouble,
PALPATION
preexisting diabetes, lung disease, Heart
obesity, or hypertension?
● Do you have high blood pressure or high ● Use the ball of the hand to detect
cholesterol? vibrations or "thrills" which may be
● Do your feet and ankles ever swell? caused by murmurs.
● Do you cough frequently? ● Use the fingertips or palmar surface to
● Do you have chest pain? When? How detect pulsations.
long does it last? How often does it occur? ● Palpate for thrills and pulsations in each
Describe the pain. Do you also feel it in area: Aortic, Pulmonic, Tricuspid and
your arms, neck, or jaw? Mitral.
● What are you doing before the pain
begins? ➢ a. Aortic area - palpate on the 2nd right
● Do you have any other symptoms with the Intercostal space, close to the sternum.
pain (nausea, shortness of breath, ➢ b. Pulmonic area - palpate on the 2nd
sweating, dizziness)? left intercostal space close to the
● What have you tried to relieve the pain? sternum
● Does it work? ➢ c. Tricuspid area - use the palm of the
● Describe your energy level. Are you hand to detect any heaving or thrusting
frequently tired? Do you have unusual of the precordium
fatigue?
● Do you have fainting spells or dizziness? If Palpate in the 5th right intercostal space (ICS)
so, how often? When was the last time? next to the sternum.
● What is your stress level? ➢ d. Mitral area - palpate in the 5th ICS,
● Do currently or have a history of smoking, left midclavicular area.
drinking alcohol, using caffeine, using
prescriptive or recreational drugs? This is the apex of the heart PMI (Point of
● Describe your exercise habits. Maximal Impulse)
● Describe your dietary pattern and Intake.
APICAL PULSE OR POINT OF resting pulse may be between 40 and
MAXIMAL IMPULSE (PMI) 60 beats per minute.
Can be visible just medial to the left

midclavicular line at the fourth or fifth ICS. With
female clients, displace the breast tissue.
INSPECTION & PALPATION
Palpate where you visualized it. Otherwise, try Neck Vessels
to palpate the location to feel the pulsations. Vital signs
● Pulse and blood pressure reflect
Normal Findings cardiovascular status.
● There should be no thrills or other ● Inspect jugular veins with the client in
pulsations. Thrills are vibrations bed with the head of the bed at a 30° to
caused by turbulence of blood moving 45° angle to assess for right-sided heart
through valves that are transmitted
failure.
through the skin -feels similar to a
purring cat.
● The apical pulse should be felt in the Appearance
left 5th ICS midclavicular area. It is a ● No neck vein distention
sharp, quick impulse.
JUGULAR VENOUS PRESSURE
(JVP)
PERCUSSION Measure at less than 2.5 cm (1 in) above the
Heart
sternal angle using the following technique:
Percuss outward from the sternum with the ● Place one ruler vertically at the sternal
stationary finger parallel to the Intercostal angle.
space until dullness is no longer heard. ● Locate the pulsation in the external
jugular vein and place the straight edge
AUSCULTATION of another ruler parallel to the floor at
Heart the level of the pulsation.
● Line up the two rulers as a T square,
● Place the stethoscope in the pulmonic
or aortic area. Begin by identifying the keeping the horizontal ruler at the level
first (S1) and 2nd (S2) heart sounds. of pulsation.
● S1 ("lub") is caused by the closing of ● Measure JVP at the level where the
the tricuspid and mitral valves. horizontal ruler intersects the vertical
● S2 ("dub") results from the closing of ruler.
the aortic and pulmonic valves. ● Bilateral pressures greater than 2.5 cm
(1 in) are considered elevated, and a
Count the rate and note the rhythm of the
apical pulse. finding of right-sided heart failure.
One-sided pressure elevation indicates
Listen to the four areas - Aortic, Pulmonic, obstruction.
Tricuspid, Mitral and the Erb's point (3" left ICS ○ Examine one carotid artery at a
close to the sternum). time. If you occlude both arteries
simultaneously during palpation,
Use the diaphragm of the stethoscope first
(detects higher pitched sounds) and then the client loses consciousness
Use the bell (detects lower pitched sounds) as a result of inadequate
circulation to the brain
Normal Findings
● Normally, two sounds are heard -
"lub" and "dub"
● The heart sounds are regular with a
rate of 60 to 100 beats per minute (in
adults). In the athlete or jogger, the
AUSCULTATION Heave or lift
Neck Vessels Sustained forceful thrusting of the ventricle
during systole
Locations to Assess for Bruits
● Carotid arteries S3 (ventricular gallop)
Abnormal for person over 35 y.o; indicates
○ Over the carotid pulses
congestive heart failure
● Abdominal aorta
○ Just below the xiphoid process S4 (atrial gallop)
● Renal arteries Indicates congestive heart failure
○ Midclavicular lines above the
umbilicus on the abdomen Diminished pulse
● Iliac arteries Feels small or weak "thread"
○ Midclavicular lines below the
Full, bounding pulse
umbilicus on the abdomen Easily palpable, pounds over fingertips
● Femoral arteries
○ Over the femoral pulses
ABNORMAL FINDINGS Breast and Lymphatic System

Heart and Neck Vessels For clients who have had a mastectomy, breast
augmentation, or reconstruction, palpate the
Chest pain incisional lines. Look for lymphedema in clients
Indicates Inadequate myocardial tissue who have impaired lymphatic drainage on the
oxygenation.
affected side.
Dyspnea on exertion (DOE)
Instruct clients who do not currently perform
Orthopnea monthly breast self-examination (BSE) to inspect
Need to assume a more upright their breasts in front of a mirror and palpate them
position to breath. during a shower. The optimal time is right after
menstruation ends. Clients who are pregnant or
Cough, sputum production, hemoptysis
postmenopausal should perform BSE on the
Fatigue, which is worse at night Due to same day of each month.
decreased cardiac output.
Equipment:
Cyanosis or pallor ✓ Examination gown and drape
Occurs with low cardiac output, results to ✓ Gloves
decreased tissue perfusion
✓ Small pillow or folded towel
Edema ✓Centimeter ruler
Caused by heart failure ✓Client handout for Breast Self-Examination
(BSE)
Nocturia
Recumbency at night promotes fluid Documentation of Nodules
reabsorption and excretion. ✓ Location (quadrant or clock method)
✓ Size (centimeters)
Murmurs
Blowing, swishing sounds that occur with ✓ Shape
turbulent blood flow in the heart or great ✓ Consistency (soft, firm, or hard)
vessels ✓ Discreteness (well-defined borders of
✓ Tenderness
Bruit over carotid artery ✓ Erythema
✓ Dimpling or retraction over the mass
Jugular vein distention
Indicates heart failure ✓ Lymphadenopathy
✓ Mobility
PALPATION
Health History: Review of Systems Questions to
Breast and Lymphatic System
ask
Palpate axillary and clavicular lymph nodes
● Do you perform breast self-examinations? with the client sitting with her arms at her sides.
How often? Expect them to be nonpalpable with no
● Have you noticed any tenderness or tenderness.
lumps? For women: Does this change with
your menstrual cycle? Breast Examination
● Do you have any thickening, pain,
drainage, distortion, or change in breast ● Wear gloves if skin is not intact. Feel for
size, or any retraction or scaling of the lumps using the finger pads of your
nipples? three middle fingers. The best position
● For clients over 40: How often are you is for the client to be lying down with the
having mammograms? arm up by her head and a small pillow
● Has anyone in your family had breast or folded towel under the shoulder of
cancer? Are you aware of the risks for the side you are examining. This
breast cancer? position spreads the breast tissue more
evenly over the chest wall, allowing for
easier palpation.
INSPECTION
Breast and Lymphatic System ● Palpate each breast from the sternum to
the posterior axillary line, and from the
Position Client clavicle to the bra line (including the
areola, nipple, and tail of Spence) using
WOMEN: Four positions (sitting or standing) one of three techniques.
Arms at the side ● Circular pattern

Arms above the head ● Wedge pattern
Hands on the hips pressing firmly ● Vertical strip pattern
Leaning forward (arms out in front or on hips)
● Compress the nipples carefully between
MEN: In sitting or lying position (with arms at your thumb and Index finger to check
the side only) for discharge (unexpected in
nonlactating women). Note the color,
Inspect for: consistency, and odor of any discharge.
● For pendulous breasts, use one hand to
Size, symmetry (One breast is often slightly support the lower portion of the breast
larger than the other.) while using your other hand to palpate
Shape (convex, conical, pendulous) breast tissue against the supporting
Symmetric venous patterns and consistency of hand.
skin color
No lesions, edema, erythema (Rashes and PALPATION
ulcerations are unexpected findings.) Breast and Lymphatic system
Round or oval shape of areola
Darker-pigmented areola and nipple
Direction of nipples (Nipples are usually EXPECTED FINDINGS
everted; recent Inversion is unexpected.)
Bleeding or discharge from the nipples WOMEN
For women with large breasts, check for Breasts firm, dense, elastic, and without lesions
excoriation under the breasts. or nodules
Breast tissue granular or lumpy bilaterally in
some women
MEN
No edema, masses, nodules, or tenderness
Areolas round and darker pigmented
UNEXPECTED FINDINGS
WOMEN
Fibrocystic breast disease: tender cysts often
more prominent during menstruation
MEN
Unilateral or bilateral (but asymmetrical)
gynecomastia in adolescent boys or bilateral
Vertical Chest Landmarks Use the following
gynecomastia in older adult males
landmarks to perform assessments and
describe findings.
Thorax and Lungs ✓ The anterior axillary line is through the anterior
● This examination includes the anterior and axillary folds.
posterior thorax and lungs. ✓ The midaxillary line is through the apex of the
● Use the techniques of inspection, axillae.
palpation, percussion, and auscultation. ✓ The posterior axillary line is through the
posterior axillary fold.
Equipment:
● Examination gown and drape The right and left scapular lines are through
● Gloves the inferior angle of the scapula.
● Mask ✓ The vertebral line along the center of the spine
● Stethoscope
● Light source
● Centimeter ruler
● Skin marker
● Wristwatch or clock that allows for
counting seconds
Positioning
Assess the posterior thorax with the client sitting
or standing. Assess the anterior thorax with the
client sitting, lying, or standing. Health History: Review of systems
Questions to ask
Anatomical Reminder The right lung has three 1. Are you exposed to secondhand smoke?
lobes; the left lung has two lobes. Auscultate the 2. Are you exposed to environmental
right middle lobe via the axillae. pollutants in your work area or residence?
3. Has anyone in your family had lung cancer
Vertical Chest Landmarks or tuberculosis? Have you had any
Use the following landmarks to perform exposure to tuberculosis?
assessments and describe findings. 4. Do you receive an influenza vaccine every
✓ The midsternal line is through the center of the year?
sternum. 5. Have you received a pneumonia vaccine?
✔The midclavicular line is through the midpoint of 6. Have you had a TB test?
the clavicle.
INSPECTION ● Palpate the chest wall using the palms of
Shape both hands, comparing side to side from
● Thorax and Lungs top to bottom.
● The anteroposterior diameter is one third ● Ask the client to say "99" each time you
to one half of the transverse diameter. move your hands.
Symmetry EXPECTED FINDINGS

● The chest is symmetric with no deformities Vibration Is symmetric and more pronounced at
of the ribs, sternum, scapuls, or vertebrae, the top, near the level of the tracheal bifurcation.
and equal movements during respiration.
PERCUSSION
Intercostal Space Thorax and Lungs
● No excessive retractions. ● Compare sounds from side to side.
Percussion of the thorax elicits resonance.
Respiratory Effort
● Rate and pattern: 12 to 20/min and regular UNEXPECTED FINDINGS AND SIGNIFICANCE
● Character of breathing (diaphragmatic, Dullness: In fluid or solid tissue, this can indicate
abdominal, thoracic) pneumonia or a tumor. Hyperresonance: In the
● Use of accessory muscles presence of air, this can indicate pneumothorax or
● Chest wall expansion emphysema.
● Depth of respirations: unlabored, quiet
breathing
AUSCULTATION
Thorax and Lungs
COUGH
EXPECTED SOUNDS
TRACHEA
✔Bronchial: Loud, high-pitched, hollow
If productive, note the color and consistency of
quality, expiration longer than Inspiration over the
sputum.
trachea
✓Bronchovesicular: Medium pitch, blowing
PALPATION sounds and intensity with equal inspiration and
Thorax and Lungs expiration times over the larger airways ✓
● Surface characteristics include ✓Vesicular: Soft, low-pitched, breezy sounds,
tenderness, lesions, lumps, and inspiration three times longer than expiration over
deformities. most of the peripheral areas of the lungs
● Tenderness is an unexpected finding.
● Avoid deep palpation if the client reports UNEXPECTED OR ADVENTITIOUS SOUNDS
pain or tenderness. ● Crackles or rales: Fine to coarse bubbly
● Chest excursion or expansion of the sounds
posterior thorax ● (not cleared with coughing) as air passes
● With thumbs aligned parallel along the through
spine at the level of the tenth rib, and the ● fluid or re-expands collapsed small
hands flattened around the client's back, airways
Instruct the client to take a deep breath. ● Wheezes: High-pitched whistling, musical
Move your thumbs outward approximately sounds as air passes through narrowed or
5 cm (2 In) when the client takes a deep obstructed airways, usually louder on
inspiration. expiration
● Rhonchi: Coarse, loud, low-pitched
PALPATION rumbling sounds during either Inspiration
Thorax and lungs or expiration resulting from fluid or mucus,
● Vocal (Tactile) Fremitus can clear with coughing
● Pleural friction rub: Dry, grating, or
rubbing sound as the Inflamed visceral
and parietal pleura rub against each other ● Concave: A sunken appearance
during inspiration or expiration ● Distended: A large protrusion of the
● Absence of breath sounds: From abdomen due to fat, fluid, or flatus
collapsed or surgically removed lobes ● Fat: The client has rolls of fat tissue along
her sides, and the skin does not look taut.
MODULE 5: Unit 5B: PHYSICAL ● Fluid: The flanks also protrude, and when
the client turns onto her side, the
ASSESSMENT
protrusion moves to the dependent side.
(Abdomen)
● Flatus: The protrusion is mainly midline,
and there is no change in the flanks.
Assessing the Abdomen
● Hernias: Protrusions through the
This examination includes observing the shape of
abdominal muscle wall are visible,
the abdomen, palpating for masses, and
especially when the client raises her head.
auscultating for vascular sounds.
MOVEMENT OF THE ABDOMINAL WALL
Ask the client to urinate before the abdominal
● Peristalsis: Wavelike movements visible
examination. Have the client lie supine with arms
in thin adults or in clients who have
at sides and knees slightly bent.
Intestinal obstructions.
● Pulsations: Regular beats of movement
Imagine vertical and horizontal lines through the
midline above the umbilicus are expected
umbilicus to divide the abdomen into four
findings in thin adults, but a pulsating
quadrants with the xiphoid process as the upper
mass is unexpected.
boundary and the symphysis pubis as the lower
boundary.
EQUIPMENT
● Stethoscope
● Tape measure or ruler
● Marking pen
INSPECTION
Note any guarding or splinting of the abdomen. •

Inspect the umbilicus for position, shape, color,
inflammation, discharge, and masses.
ASSESS THE SKIN FOR:

● Lesions: Bruising, rashes, or other
primary lesions Scars: Location and length
● Silver striae or stretch marks (expected
findings)
● Dilated veins: An unexpected finding
possibly reflecting cirrhosis or inferior vena AUSCULTATION
cava obstruction Assessing the Abdomen
● Jaundice, cyanosis, or ascites: Possibly
reflecting cirrhosis ● Bowel sounds result from the movement
of air and fluid in the intestines. The most
SHAPE OR CONTOUR appropriate time to auscultate bowel
● Flat: In a horizontal line from the xiphoid sounds is in between meals.
process to the symphysis pubis
● Convex: Rounded
TECHNIQUE: Listen with the diaphragm of the ○ Measure the distance between the
stethoscope in all four quadrants. two marks for the size of the liver
span.
EXPECTED SOUNDS: High-pitched clicks and ○ The expected finding is 6 to 12 cm
gurgles 5 to 35 times/min. To make the (2.4 to 4.7 In).
determination of absent bowel sounds, you must
hear no sounds after listening for a full 5 min. PALPATION
UNEXPECTED SOUNDS: Loud, growling sounds
(borborygml) are hyperactive sounds and indicate Palpate tender areas last.
Increased gastrointestinal motility. Possible Light
causes Include diarrhea, anxiety, bowel ● Use the finger pads on one hand to
Inflammation, and reactions to some foods. palpate to a depth of 1.3 cm (0.5 In) in
● Friction rubs result from the rubbing each quadrant.
together of inflamed layers of the ● Expect softness, no nodules, and no
peritoneum. guarding.
● Listen with the diaphragm over the liver ● The bladder is palpable if full; otherwise, it
and is nonpalpable.
● spleen. Deep
● Ask the client to take a deep breath while ● TWO-HANDED APPROACH: The top
you listen for any grating sounds (like hand depresses the bottom hand 2.5 to
sandpaper rubbing together). 7.5 cm (1 to 3 in) in depth. The bottom
hand assesses for organ enlargement or
masses.
Percussion ● EXPECTED FINDINGS: The stool can be
Assessing the abdomen palpable in the descending colon.
Rebound tenderness (Blumberg's sign)
● Expect to hear tympany over most of the An indication of irritation or inflammation
abdomen. A lower-pitch tympany over the somewhere in the abdominal cavity. Use the
gastric bubble in the left upper quadrant is following technique in all four quadrants.
common. ● Apply firm pressure for 4 seconds with the
● Expect dullness over the liver or a hand at a 90° angle and with the fingers
distended bladder. extended.
● Assess for kidney tenderness by fist ● After releasing the pressure, observe the
percussion over the costovertebral angles client's response to see if releasing the
at the scapular lines on the back. The pressure caused pain.
expected finding is no tenderness. ● Ask about pain and tenderness.
● The liver span is a measurement of liver ● Never palpate an abdominal mass, tender
size at the right midclavicular line. organs, or surgical incisions deeply
○ Establish the lower border of the
liver by percussing upward from MODULE 5: Unit 5B: PHYSICAL
below the umbilicus at the right
ASSESSMENT
midclavicular line until tympany
(Neurologic Assessment)
tums to dullness. Make a mark.
○ Establish the upper border by
Anatomy and Physiology
percussing downward, starting at
CENTRAL NERVOUS SYSTEM
the right midclavicular line over the
lung until resonance turns to
● encompasses the brain and spinal cord-
dullness.
covered by meninges
○ Make a mark.
● The subarachnoid space surrounds the
brain and spinal cord is filled with
cerebrospinal fluid, which is formed in the
ventricles of the brain and flows through PERIPHERAL NERVOUS SYSTEM
the ventricles Into the space. ● Carrying information to and from the CNS
● Electrical activity of the CNS is governed ● Consists of 12 pairs of cranial nerves and
by neurons located throughout the 31 pairs of spinal nerves.
sensory and motor neural pathways.
● contains upper motor neurons that These nerves are categorized as two types of
influence lower motor neurons, located fibers:
mostly Inthe peripheral nervous system. ● Somatic fibers carry CNS impulses to
voluntary skeletal muscles: mediates
Brain conscious, or voluntary activities
Located in the cranial cavity, the brain has four ● Autonomic fibers carry CNS impulses to
major divisions: the cerebrum, the diencephalon, smooth, involuntary muscles (in the heart
the brain stem, and the cerebellum and glands); mediates unconscious, or
involuntary, activities.
Spinal Cord
is located in the vertebral canal and extends from
the medulla oblongata to the first lumbar vertebra.
A complete neurologic examination consists
angry/irritable/edgy lately?"
of evaluating the following five areas:
● Mental status Affect: An observed expression of inner feeling
● Cranial nerves Appropriateness to situation, consistency with
● Motor and Cerebellar System mood, congruence with thought content.
● Sensory system ● Fluctuations: Labile, even Range:
● Reflexes Broad, restricted
● Intensity: Blunted, flat, nonnal Intensity
● Quality: Sad, angry, hostile, indifferent,
euthymic, dysphoric, detached, elated,
euphoric, anxious, animated, irritable.
IV.Content of thought
❖ "What do you think about when you are
sad/angry?"
❖ "What's been on your mind lately?"
❖ "Do you find yourself ruminating about
things?" "Are there thoughts or images
that you have a really difficult time
getting out of your head?"
❖ "Are you worried/scared/frightened
about something or other?"
❖ "Do you have personal beliefs that are
not shared by others?" (Delusions are
fixed, false, unshared beliefs.)
❖ "Do you ever feel
detached/removed/changed/different
from others around you?"
❖ "Do things seem unnatural/unreal to
Mental Status Examination you?"
I. General Behavior and Appearance ❖ "What do you think about the reports in
Galt, posture, clothes, grooming mannerisms, papers such as The National Enquirer?"
gestures, psychomotor activity, expression, eye ❖ "Do you think someone or some group
contact, ability to follow commands/requests, intends to harm you in some way?
compulsions. ❖ " In response to something the patient
says]
II. Stream of Talk ❖ "What do you think they meant by that?"
A. Quantity Possible descriptors: Does it ever seem like people are
Talkative, spontaneous, expansive, paucity, stealing your thoughts, or perhaps
poverty inserting thoughts into your head? Does
B. Rate Possible descriptors: it ever sound like your own thoughts are
Fast, slow, normal, pressured. broadcast out loud?"
C. Volume (Tone)-Possible descriptors: ❖ "Do you ever see (visual), hear
Loud, soft, monotone, weak, strong (auditory), smell (olfactory), taste
D. Fluency and Rhythm-Possible (gustatory), and feel (tactile) things that
descriptors: are not really there, such as voices or
Slurred, clear, with appropriately placed visions?" (Hallucinations are false
inflections, hesitant, with good articulation, perceptions)
aphasic. ❖ "Do you sometimes misinterpret real
things that are around you, such as
III. Mood and affective responses muffled noises or shadows?"
Mood: A sustained state of inner feeling
❖ "How are your spirits?"
V.Intellectual Capacity
❖ "How are you feeling?"
❖ "Have you been
A. Information and Vocabulary-Suggested
discouraged/depressed/low/blue lately?"
patient instructions:
❖ "Have you been
● "Name the last 5 presidents." (Clinton,
energized/elated/high/out of control
Bush, Reagan, Carter, Ford, Nixon,...)
lately?" "Have you been
❖ "Name the current president, vice
president, governor, and mayor." from 100, and then keep subtracting 7
B. Vocabulary from that number as far as you can go
● Grade school level, high school level, ❖ (Serial 3's) Starting with 20, subtract 3
fluent, consistent with education. from 20, and then keep subtracting 3
C. Abstraction from that number as far as you can go."
1. Similarities- "How are the following items [Monito for speed, accuracy, effort
similar?" required, and monitor patient reactions
❖ "an apple and an orange" to the request)
(round-concrete, fruit -abstract)
❖ "a chair and a table" (made of wood
-concrete, furniture -abstract)
❖ "a watch and a ruler" (measurement MODULE 5: Unit 5B: PHYSICAL
instruments-abstract) ASSESSMENT
(Cranial Nerves)
2. Proverbs-"How would you describe the
meaning of the following sayings?"
❖ "People living in glass houses should
not throw stones."
❖ "A bird in the hand is worth two in the
bush."
❖ "You shouldn't cry over spilt milk."
❖ "Two heads are better than one."
❖
VI.Sensorium
● a.Consciousness - Awareness of self

and environment
● b.Attention Span - Recite months
backward, spell WORLD backwards
● c.Orientation - Time, person, place
● d. Memory Test for romats and recent
memory, provide pt an address, color, or
object and ask to repeat at the end of
neuro exam
● e.Fund of Information - Current events
● f. insight, judgment and planning
❖ "What brings you here today?"

❖ "What seems to be the problem?"
❖ "What do you think is causing your
problems?"
❖ "How do you understand your
problems?"
❖ "How would you describe your role in
this situation?
❖ "Do you think that these thoughts,
moods, perceptions, are abnormal?"
❖ "How do you plan to get help for this
problem?"
❖ "What will you do when, occurs?”
❖ "How will you manage it?
❖ "If you found a stamped, addressed
envelope on the street, what would you
do with it?"
❖ "If you were in a movie theater and
smelled smoke, what would you do?"
● g.calculation
❖ (Serial 7) Starting with 100, subtract 7

CRANIAL NERVES
Motor and Cerebellar System
REFLEXES
MODULE 5: Unit 5B: PHYSICAL in the symmetry of these findings should
ASSESSMENT be noted..
(Peripheral Vascular System)
HEALTH HISTORY: REVIEW OF SYSTEMS
Assessing the peripheral vascular system QUESTIONS TO ASK
includes measuring the blood pressure, palpating ● Have you noticed any change in your skin
peripheral pulses, and inspecting the skin and color? If so, is the change widespread or
tissues to determine perfusion (blood supply to an just in one area?
area) to the extremities. ● Do you have a rash? Where? Does it itch?
How long have you had it? What have you
Certain aspects of peripheral vascular used to treat the rash?
assessment are often incorporated into other ● Is your skin excessively dry or oily? Does
parts of the assessment procedure. this change with the seasons? Do you use
anything to treat it?"
Equipment: ● Have you developed any new moles or
✓Centimeter tape lesions? Have any of the moles or lesions
✓ Stethoscope changed in any way (color, borders, size)?
✓Doppler ultrasound device ● How often are you out in the sun? Do you
✓Conductivity gel use sunscreen or wear protective clothing
✓Tourniquet and a hat?
✓Gauze or tissue ● Do you have any swelling? If in your legs,
✓Waterproof pen is it in both legs? Does the swelling cause
✔Blood pressure cuff pain? What do you do to relieve the
swelling? Does it occur at any particular
Lifespan Considerations time of day?
Infants
● Screen for coarctation of the aorta by
INSPECTION
palpating the peripheral pulses and Peripheral Vascular System - Upper Extremities
comparing the strength of the femoral (Arms)
pulses with the radial pulses and apical
pulse. If coarctation is present, femoral ✓ Observe skin over extremities for color, pallor,
pulses will be diminished and radial rubor (redness), hair distribution.
pulses will be stronger.
✓Inspect the arms for any superficial vessels.
Children
● Changes in the peripheral vasculature, NORMAL FINDINGS:
such as bruising, petechiae, and ● Extremities should be symmetrically even
purpura, can Indicate serious systemic in color, warmth and moisture, without
diseases in children (e.g., leukemia, swelling.
meningococcemia).
● Swelling of feet may occur after prolonged
Older adults standing or sitting but will disappear
● The overall efficiency of blood vessels readily when extremity is elevated.
decreases as smooth muscle cells are
replaced by connective tissue. The Note temperature of skin over extremities,
lower extremities are more likely to comparing one side to the other.
show signs of arterial and venous
Impairment because of the more distal
and dependent position. PALPATION
● Peripheral vascular assessment should Peripheral Vascular System - Upper Extremities
always include upper and lower (Arms)
extremities"
● temperature, color, pulses, edema, skin ● Palpate pulses - radial and then brachial
integrity, and sensation. Any differences
comparing symmetry from side to side.
● Test range of motion (ROM) and muscle ✓ Both legs are symmetric in size, with no
strength of hands, arms and shoulders. swelling or atrophy.
Normal Findings:
● Radial pulses on both arms are present ABNORMAL FINDINGS
and approximately equal. ● Skin in the legs appears pale with
vasoconstriction; reddish with vasodilation:
Amplitude (Force) of pulses cyanotic with poor oxygenation.
● 3+= Increased, full, bounding
● Thin, skinny skin with pallor and coolness,
● 2+-normal
● 1+-weak loss of hair, ulcers, gangrene in the legs
● 0 = absent indicate arterial insufficiency.
● Bilateral edema In the legs may Indicate
● Full ROM of arms, normal muscle systemic Illnesses affecting the heart or
strength of hands, arms and shoulders. kidneys.
● The two arms should be symmetric in ● Acute, unilateral painful swelling in the
size.
legs may Indicate deep vein thrombosis.
● Brown discoloration in the legs occurs with
ABNORMAL FINDINGS: chronic venous stasis due to hemosiderin
● Cold, clammy and pale hands and arms. deposits from red blood cell degradation.
This signifies vasoconstriction or
decreased cardiac output. PALPATION
● Edema of upper extremities. This may Peripheral Vascular System - Lower Extremities
indicate poor venous return or obstruction
of lymphatic drainage. ● Palpate for skin temperature along the
● Needle tracks in antecubital fossa may legs down to the feet with dorsum of the
indicate IV drug use; linear scar in the hand.
wrists may signify past self-inflicted Injury. ● Assess for Homan's sign.
● Full, bounding pulse (3+). This occurs with ● Palpate the inguinal lymph nodes.
exercise, anxiety, fever, anemia and ● Palpate the following arteries in both legs:
hyperthyroidism. femoral, popliteal, dorsalis pedis and
● Weak, thready pulse. This occurs with posterior tibial.
shock and peripheral arterial disease. ● Check for pretibial edema.
INSPECTION ABNORMAL FINDINGS

Peripheral Vascular System - Lower Extremities ● Calf pain (positive Homan's Sign) may
Indicate deep vein thrombosis, superficial
● While in supine position, expose the legs. phlebitis,
Keep the genitalia covered. ● Achilles tendinitis, gastrocnemius and
● Inspect both legs together. Note skin color, plantar muscle injury and lumbosacral
hair distribution, venous pattern, size disorders.
(swelling or muscle atrophy) and any skin ● Enlarged inguinal lymph nodes, tender or
lesions or ulcers. fixed in the area.
● Measure the calf circumference with tape ● A bruit occurs with turbulent blood flow,
measure (if lower legs appear asymmetric indicating partial arterial occlusion
or unequal in size). ● (atherosclerosis).
● Bilateral, dependent, pitting edema occurs
NORMAL FINDINGS with heart failure, diabetic neuropathy and
Hair covers the legs. liver cirrhosis.
✓ The venous pattern in the legs is ● Unilateral edema occurs with occlusion of
normally flat and barely visible. a deep vein.
● Unilateral or bilateral edema occurs with
Note obvious varicosities. lymphatic obstruction.
● Varicosities occur in the saphenous veins. ● Test the lower legs for strength and
The veins become visible, dilated and sensation.
tortuous.
If pitting edema is present, classify it

on the following scale: Abnormal Findings
❖ 1+ Mild pitting, slight indentation, no ● Elevational pallor indicates arterial
perceptible swelling on the leg (or 1cm insufficiency.
Indentation) ● Dependent rubor (deep blue to red)
❖ 2+ Moderate pitting, Indentation subsides occurs in severe arterial insufficiency,
rapidly (or 2cm indentation) ● Delayed venous filling occurs with arterial
❖ 3+ Deep pitting, indentation remains for a insufficiency.
short time, leg looks swollen (or 3cm ● Motor loss occurs with severe arterial
indentation) deficit.
❖ 4+ Very deep pitting, indentation lasts a ● Sensory loss occurs with arterial deficit,
long time, leg is very swollen (or 4cm especially diabetes.
indentation)
The Ankle-Brachial Index (ABI)
Manual Compression Test ● Apply a regular arm blood pressure cuff
● Done while the patient is in a standing above the ankle and determine the
position. It involves measuring the length systolic pressure in either the posterior
of the varicose vein to determine whether tibial or dorsalis pedis artery.
its valves are competent. ● Divide the figure by the systolic pressure
● Place one hand on the lower part of the of the brachial artery.
varicose vein and compress the vein with ● The normal ankle pressure is slightly
the other hand about 15 to 20 cm. greater than or equal to the brachial
Competent valves will prevent a wave pressure. Thus, the normal ABI is usually
transmission and the distal/lower fingers 1.0 to 1.2
will feel no change.
Example:
Abnormal Findings
● A palpable wave transmission occurs
when the valves are incompetent
Color Changes
MODULE 5: Unit 5B: PHYSICAL
● When arterial insufficiency is suspected, ASSESSMENT
raise the legs about 30 cm (12in) off the (Musculo-Skeletal System)
table and ask the patient to wag the feet
for about 30 seconds to drain off venous Examination of the musculoskeletal system
blood. includes assessing both its structure and function.
● The skin color now represents only the
effect of arterial blood. Assessment involves examining each joint,
● The feet will normally look a little pale but muscle, and the surrounding tissues bilaterally
still should be pink. and comparing findings for symmetry.
● Then have the patient sit up with the legs
over the side of the table. Compare the Use the techniques of inspection and palpation to
color of both feet. Note the time it takes for assess the musculoskeletal system.
color to return to the feet (normal <10sec)
● Note also the time it takes for the feet to fill Equipment:
(normal: about 15 sec) ✓Tape measure
✓Drape or cover for privacy
ASSESSMENT
Musculo-Skeletal System ✓Do you have any pain in your joints or
muscles?
✔Gait: Manner or style of walking ✓Do you have any stiffness, weakness, or
✔Alignment: Position of the joints, tendons, twitching? Have you fallen recently?
muscles, and ligaments while sitting, standing ✓ Are you able to care for yourself?
and lying ✓Do you have any physical problems that limit
✔Symmetry, muscle mass your activities?
✔Muscle tone: Normal state of balanced muscle ✓Do you exercise or participate in sports on a
tension allowing one to maintain positions such regular basis?
as sitting or standing ✔For postmenopausal women: What was your
✔Range of motion (ROM): Maximum amount of maximum height?
movement of a joint-sagittal (left or right), ✓Do you take calcium supplements?
transverse (side to side) and frontal (front to
back). INSPECTION
✔Any Involuntary movements Musculo-Skeletal System
✔Indications of inflammation: Redness,
swelling, warmth, tenderness, loss of function SYMMETRY: Observe and compare both sides of
✔Gross deformities the body for symmetry.
EXPECTED RANGE OF MOTION OF JOINT HEIGHT: Measure for comparison over time.
MOVEMENT Gradual height loss is a common finding as a
✓ Flexion: Movement that decreases the angle person ages.
between two adjacent bones
✓ Extension: Movement that increases the POSTURE: Observe when the client is unaware.
angle Expected finding: client standing with head erect
between two adjacent bones with both shoulders and hips at equal heights
✓ Hyperextension: Movement of a body part bilaterally.
beyond its normal extended position
✓ Supination: Movement of a body part so the ✓SPINE: Inspect from the side.
ventral
(front) surface faces up Note the following curvatures:
✓ Pronation: Movement of a body part so the ✓ Expected curvatures (posteriorly)
ventral ● Concave cervical spine
(front) surface faces down ● Convex thoracic spine
✓ Abduction: Movement of an extremity away ● Concave lumbar spine
from the midline of the body ● Convex sacral spine
✓ Adduction: Movement of an extremity toward
the midline of the body
UNEXPECTED FINDINGS
✓ Dorsiflexion: Flexing the foot and toes upward ● Kyphosis: exaggerated curvature of the
✓ Plantar flexion: Bending the foot and toes thoracic spine (common among older
downward adults)
✓ Eversion: Turning a body part away from ● Lordosis: exaggerated curvature of the
midline lumbar spine (common during the
✓ Inversion: Turning a body part toward the toddler years and pregnancy)
● Scoliosis: exaggerated lateral curvature
midline
✓ External rotation: Rotating a joint outward
✓ Internal rotation: Rotating a joint inward INSPECTION & PALPATION
Musculo-Skeletal System
HEALTH HISTORY: REVIEW OF SYSTEMS
Expect equal range of motion (ROM) in the
QUESTIONS TO ASK joints bilaterally.
✓ Expected finding:
Assess passive ROM by moving the client's joints
through his full range of movements. Do not move
No tenderness, with spinal vertebrae that are
a joint past the point of pain or resistance.
midline.
Assess active ROM by having the client repeat

the movements the nurse demonstrates. Legs, feet, and toes
● Observe muscles.
Assess joints for warmth, inflammation, edema,
stiffness, crepitus, deformities, tenderness,
● Note hair distribution
limitations, and instability. Assess the following ● Palpate joints of hips and test ROM.
joints: With the client standing, inspect symmetry and
● Temporomandibular joint shape of hips.
● Shoulders
● Elbows Palpate for stability,
● Wrists and hands
● Spine (scoliosis) tenderness, and crepitus. • With the client supine,
● Hips ask the client to perform ROM exercises.
● Knees
● Ankles, feet
Muscles should be firm, symmetric, and have

equal strength bilaterally. The dominant side is
usually slightly larger; less than a 1 cm difference
is not significant.
Size variations:
- Hypertrophy: Enlargement of
muscle due to strengthening
- Atrophy: Decrease in muscle size
due to disuse; feels soft and boggy
● During ROM, assess tone: slight
resistance of the muscles during
relaxation.
● Assess the strength of muscle groups by
asking the client to push or pull against
resistance.
- Expected finding: strength equal, Palpate legs and feet, knees and ankles
or slightly stronger, on the ● Palpate for tenderness, warmth,
dominant side of the body. consistency, and nodules. Begin palpation
- Assess for muscle tremors. 10 cm above the patella, using your
fingers and thumb to move downward
● Inspect and palpate the spine from the toward the knee.
back for any lateral deviations or scoliosis.
○ Instruct the client to bend at the
waist with the arms reaching for Palpate legs and feet, knees and ankles
the toes. Palpate ankles and feet for tenderness, heat,
○ Inspect and palpate down the swelling, or nodules.
spine using the thumb and
forefinger. Assess capillary refill
○ Inspect and palpate the spine
again with the client standing.
Test sensations (dull and sharp), two-point
discrimination, reflexes, position, sense and
vibratory sensation.
Perform heel-to-shin test

● Place the patient to lie supine
● Ask the patient to place the heel on the
opposite knee, and run it down the shin
from the knee to the ankle. Observe tandem walk
● Ask the client to walk in heel-to-toe
Secure gown and assist client to standing fashion, next on the heels, then on the
position toes.
● Demonstrate the walk first; then stand
Observe for spinal curvatures and check for close by in case the client loses balance.
scoliosis.
● Observe the cervical, thoracic, and lumbar Observe hopping on each leg
curves from the side then from behind. • Now ask the client to stand on one foot and to
● Have the client standing erect with the bend the knee of the leg he or she is standing on.
gown positioned to allow an adequate • Then ask the client to hop on that foot.
view of the spine. Repeat on the other foot.
● Observe for symmetry, noting differences
in height of the shoulders, the iliac crests Perform Romberg's test
and the buttock creases. ● Ask the client to stand erect with arms at
side and feet together.
Observe gait ● Note any unsteadiness or swaying.
● Ask the client to walk naturally across the ● Then with the client in the same body
room. position, ask the client to close the eyes
● Note posture, freedom of movement, for 20 seconds.
symmetry, rhythm, and balance. Again, note any imbalance or swaying.
Perform finger-to-nose test

● Demonstrate the finger-to-nose test to
assess accuracy of movements then ask
the client to extend and hold arms out to
the side with eyes open.
● Next say "Touch the tip of your nose first
with your right index finger, then with your
left index finger. Repeat this three times"
Next ask the client to repeat these
movements with eyes closed.
The male genitalia consists also of
external structures and internal
structures.
MODULE 5: Unit 5B: PHYSICAL

ASSESSMENT
(Genitals and Rectum)
The female genitalia consist of external

structures and internal structures.
Equipment Used
● Stool
● Light
● Speculum
● Water-soluble lubricant
● Cotton-tipped applicators
● Sterile disposable gloves
● Ayre spatula (plastic)
● Endocervical broom
● pH paper
● Feminine napkins
● Mirror
INSPECTION
Female External Genitalia
Inspect the vagina.

Unlock the speculum and slowly rotate and
remove it. Inspect the vagina as you remove the
speculum. Note the vaginal color, surface,
consistency, and any discharge.
Inspect the Mons Pubis.

Wash your hands and put on gloves. As you
begin the examination, note the distribution of
pubic hair. Also be alert for signs of infestation.
Observe and palpate inguinal lymph nodes.
Inspect the labia majora and perineum.

Observe the labia majora and perineum for
lesions, swelling, excoriation
Abnormal FIndings:
Inspect the labia minora, clitoris, urethral ● Reddened areas, lesions, and colored,
meatus, and vaginal opening. Use your gloved malodorous discharge are abnormal
hand to separate the labia majora and inspect for and may indicate vaginal infections,
lesions, excoriation, swelling, and/or discharge STDs, or cancer
● Asymmetric labia may indicate abscess.
Inspect the size of the vaginal opening and the ● Lesions, swelling, bulging in the vaginal
opening, and discharge are abnormal
angle of the vagina. Insert your gloved index findings.
finger into the vagina, noting the size of the ● Excoriation may result from the client
opening scratching or self-treating a perineal
irritation.
Inspect the vaginal musculature. ● Any loss of hymenal tissue between the
Keep your index finger inserted in the client's 3 o'clock position and the 9 o'clock
position indicates trauma (penetration
vaginal opening. Ask the client to squeeze around
by digits, penis or foreign objects) in
your finger. children.
● Absent or decreased ability to squeeze
Inspect the cervix. the examiner's finger indicates
Use a speculum. With the speculum inserted in decreased muscle tone. Decreased
position to visualize the cervix, observe cervical tone may decrease sexual satisfaction.
color, size, and position. ● Absence of pubic hair in the adult client
is abnormal.
● Lice or nits (eggs) at the base of the
Normal Findings: pubic hairs indicate infestation with
● The vagina should appear pink, moist, pediculosis pubis.
smooth, and free of lesions and ● Enlarged inguinal nodes may indicate a
irritation. It should also be free of any vaginal infection or may be the result of
colored, malodorous discharge. irritation from shaving pubic hairs.
● The labia minora appear symmetric, ● Lesions may be from an infectious
dark pink, and moist. disease such as herpes or syphilis.
● The clitoris is a small mound of ● Excoriation and swelling may be from
● erectile tissue, sensitive to touch. scratching or self-treatment of the
● The normal size of the clitoris varies. lesions.
● The urethral meatus is small and slitlike. ● In a nonpregnant woman, a bluish
● The vaginal opening is positioned below cervix may indicate cyanosis.
the urethral meatus, and may be ● In a non menopausal woman, a pale
covered partially or completely by a cervix may indicate anemia. Redness
hymen. (inflammation)
● The normal vaginal opening varies in
size according to the client's age, sexual
history, and whether she has given birth PALPATION
vaginally. Female External Genitalia
● The client should be able to squeeze
around the examiner's finger. Palpate Bartholin's glands.
● The surface of the cervix is normally
If the client has labial swelling or a history of it,
smooth, pink, and even. Normally, it is
midline in position and projects 1 to 3 palpate Bartholin's glands for swelling,
cm into the vagina tenderness, and discharge
● Pubic hair is distributed in an inverted
triangular pattern and there are no signs Palpate the urethra.
of infestation If the client reports urethral symptoms or
● There should be no enlargement or urethritis, or if you suspect inflammation of
swelling of the lymph nodes.
Skene's glands
● The labia majora are equal in size and
free of lesions, swelling, and
excoriation. Palpate the vaginal wall.
Tell the client that you are going to do a manual
examination and explain its purpose. Apply water-
soluble lubricant to the gloved index and middle
considered normal
fingers of your dominant hand. Then stand and ● Ovaries are approximately 3 x2 x1 cm
approach the client at the correct angle. Placing (or the size of a walnut) and almond-
your nondominant hand on the client's lower shaped.
abdomen, insert your index and middle fingers
into the vaginal opening. Apply pressure to the Abnormal Findings
● Swelling, pain, and discharge may
posterior wall, and wait for the vaginal opening to
result from infection and abscess
relax before palpating the vaginal walls for texture ● Drainage from the urethra indicates
and tenderness. possible urethritis. (Neisseria
gonorrhoeae or Chlamydia trachomatis)
Palpate the cervix. ● Tenderness or lesions may indicate
Advance your fingers until they touch the cervix infection.
● A hard, immobile cervix may indicate
and run fingers around the circumference.
cancer. Pain with movement of the
Palpate for cervix may indicate infection.
● Contour ● An enlarged uterus above the level of
● Consistency the pubis is abnormal; an irregular
● Mobility shape suggests abnormalities such as
● Tenderness myomas (fibroid tumors) or
endometriosis
● Enlarged size, masses, immobility. and
Palpate the uterus.
extreme tenderness are abnormal and
Move your fingers intravaginally into the opening should be evaluated
above the cervix and gently press the hand
resting on the abdomen downward, squeezing the
uterus between the two hands. Note uterine size,
position, shape, and consistency
Palpate the ovaries.

Slide your intravaginal fingers toward the left
ovary in the left lateral fornix and place your
abdominal hand on the left lower abdominal
quadrant. Press your abdominal hand toward
your intravaginal fingers and attempt to palpate
the Ovary
Normal Findings INSPECTION

Male External Genitalia
● Bartholin's glands are usually soft,
nontender, and drainage free. Inspect the base of the penis and pubic hair.
● No drainage should be noted from the Sit on a stool with the client facing you and
urethral meatus. The area is normally standing
soft and nontender.
● The vaginal wall should feel smooth, Inspect the foreskin.
and the client should not report any
Observe for color, location, and integrity of the
tenderness.
● The cervix should feel firm and soft (like foreskin in uncircumcised men.
the tip of your nose). It is rounded, and
can be moved somewhat from side to Inspect the glans.
side without eliciting tenderness. Observe for size, shape, and lesions or redness.
● The fundus, the large upper end of the
uterus, is normally round, firm, and Inspect the size, shape, and position.
smooth. In most women, it is at the level
Ask the client to hold his penis out of the way.
of the pubis; the cervix is aimed
posteriorly (anteverted position). Observe for swelling, lumps, or bulges.
However, several other positions are
Inspect the scrotal skin.
Observe color, integrity, and lesions or rashes. To
perform an accurate inspection, you must spread
out the scrotal folds (rugae) of skin. Lift the scrotal
sac to inspect the posterior skin.
Normal Findings
● Pubic hair is coarser than scalp hair.
The normal pubic hair pattern in adults
is hair covering the entire groin area,
tending to the medial thighs and up the
abdomen toward the umbilicus. The
base of the penis and the pubic hair are
free of excoriation, erythema, and
infestation.
● The urinary meatus is normally free of
discharge.
● The glans size and shape vary,
appearing rounded, broad, or even
pointed. The surface of the glans is
normally smooth, free of lesions, and
redness.
● The scrotum varies in size (according to
temperature) and shape. The scrotal
sac hangs below or at the level of the
penis. The left side of the scrotal sac
usually hangs lower than the right side.
● Scrotal skin is thin and rugated with little
hair dispersion. Its color is slightly
darker than that of the penis.
● Lesions and rashes are not normally
present. However, sebaceous cysts
(small, yellowish, firm, nontender,
benign nodules) are a normal finding.
Abnormal Findings
● Absence or scarcity of pubic hair may
be seen in clients receiving
chemotherapy. Lice or nit (eggs)
infestation at the base of the penis or
pubic hair is known as pediculosis
pubis. This is commonly referred to as
"crabs."
● A yellow discharge is usually associated
with gonorrhea. A clear or white
discharge is usually associated with
urethritis. All discharge should be
cultured.
● Chancres (red, oval ulcerations) from
syphilis, venereal warts, and pimple-like
lesions from herpes are sometimes
detected on the glans.
PALPATION
Male External Genitalia
Palpate the scrotal contents.

Palpate each testis and epididymis between your
thumb and first two fingers Note size, shape,
consistency, nodules, and tenderness.
Palpate each spermatic cord and vas deferens

from the epididymis to the inguinal ring. The
spermatic cord will lie between your thumb and
finger
Normal Findings
● Testes are ovoid, approximately 3.5 to 5
cm long, 2.5 cm wide, and 2.5 cm deep,
and equal bilaterally in size and shape.
They are smooth, firm, rubbery, mobile,
free of nodules, and rather tender to
pressure. The epididymis is nontender,
smooth, and softer than the testes.
● The spermatic cord and vas deferens
should feel uniform on both sides. The
cord is smooth, nontender, and ropelike.
Abnormal Findings
● Absence of a testis suggests
cryptorchidism (an undescended
testicle).
● Painless nodules may indicate cancer.
● Tenderness and swelling may indicate
acute orchitis, torsion of the spermatic
cord, a strangulated hernia, or
epididymitis
● Palpable, tortuous veins suggest
varicocele.
● Abeaded or thickened cord indicates
infection or cysts.
PHYSICAL ASSESSMENT
Anus & Rectum
Assessment Procedure
Inspect the perianal area
● Spread the client's buttocks and
● Inspect the anal opening and
surrounding area for the following:
- Lumps
- Ulcers
- Lesions
- Rashes
- Redness
- Fissures
- Thickening of the epithelium

The anal opening Lesions may indicate
should appear sexually transmitted
hairless, moist, and diseases, cancer, or
tightly closed. The hemorrhoids. A
skin around the anal thrombosed external
opening is more hemorrhoid appears
coarse and more swollen. It is itchy,
darkly pigmented. The painful, and bleeds
surrounding perianal when the client
area should be free of passes stool. A
redness, lumps, previously
Ulcers, lesions, and thrombosed
rashes. hemorrhoid appears
as a skin tag that
protrudes from the
anus.
MODULE 6: RELEVANT 2. Right to Informed Consent
ETHICO-LEGAL GUIDELINES IN The patient has a right to clear, truthful and
CONDUCTING HEALTH substantial explanation, in a manner and
language understandable to the patient, of all
ASSESSMENT
proposed procedures, whether diagnostic,
preventive, curative, rehabilitative or therapeutic,
A. Ethico-Legal Considerations wherein the person who will perform the said
PHILIPPINE NURSING CODE OF ETHICS procedure shall provide his name and credentials
● Promulgated by the Philippine Regulatory to the patient, possibilities of any risk of mortality
Board of Nursing or serious side effects, problems related to
● Mandated by section 9, article III of R.A. No. recuperation, and probability of success and
9173 or known as the "Philippine Nursing reasonable risk involved.
Code of Ethics for Nurse Act of 2002"
● Serves as ethico-legal basis in the practice 3. Right to Privacy and Confidentiality
of the nursing profession in the Philippines
The privacy of the patient must be assured at all
stages of his treatment. The patient has the right
INFORMED CONSENT to demand all information, communication and
An agreement by a client to accept a course of
records pertaining to his care be treated as
treatment or a procedure after being provided
complete information Including: confidential.
○ Benefits and risks of treatment
○ Alternatives to the treatment and 4. Right to Information
○ Prognosis if not treated by a In the course of treatment and hospital care, the
healthcare provider patient or legal guardian has a right to be
informed of the result of the evaluation of the
Three Major elements of Informed Consent
○ Must be given voluntarily nature and extent of the disease, any additional
○ Must be given by a client or or further contemplated medical treatment or
individual with the capacity and surgical procedures, including any other
competence to understand additional medicines to be administered and their
○ The client or individual must be generic counterpart including the possible
given enough information to be the
complications and other pertinent facts.
ultimate decision maker
Nurse's Role 5. Right to Choose Health Care

● Nurses are not responsible for explaining Provider and Facility
the procedure The patient is free to choose the health care
● Nurses act as witness that the client signs provider to serve him as well as the facility except
the consent form when he is under the care of a service facility or
● Nurses' signature confirms 3 things: when public health and safety so demands or
○ The client gave consent voluntarily when the patient expressly waives this right in
○ The signature is authentic writing.
○ The client appears competent to
give the consent 6. Right to Self determination
The patient has the right to avail himself of any
recommended diagnostic and treatment
B. Patients' Bill of Rights procedures.
A document that provides patients with
information on how they can reasonably expect 7. Right to Religious Belief
to be treated during the course of their hospital The patient has the right to refuse medical
stay. treatment or procedures which may be contrary
● These documents are, in almost all cases, to his religious beliefs, subject to the limitations
not legally-binding. described in the preceding subsection: Provided,
● They provide goals and expectations for that such a right shall not be imposed by parents
patient treatment upon their children who have not reached the
legal age in a life-threatening situation as
determined by the attending physician or the
1. Right to Appropriate Medical Care medical director of the facility.
and Humane Treatment
Every person has the right to health and medical 8. He has the right to view the content of his
care corresponding to his state of health, without medical records, except psychiatric notes and
any discrimination and within the limits of the other incrimatory information obtained about third
resources, manpower and competence available parties, with the attending physician explaining
for health and medical care at the relevant time. contents thereof.
Prohibits the disclosure or misuse of information
9. Right to Leave
about private individuals. Information collected from
The patient has the right to leave hospital or any
an individual cannot be disclosed to other
other health care institution regardless of his
organization or individual unless specifically
physical condition; Provided that:
authorized by law or by consent of the individual.
● He is informed of the medical
consequences of his decision
Three Rights under the Privacy Act:
● He shall release those involved in his care
1. Right to request their records, subject to
from any obligations relative to the
Privacy Act exemptions
consequences of his decision
2. Right to request change to their records that
● His decision will not prejudice public
are not accurate, relevant, timely or
health and safety
complete
3. Right to be protected against unwarranted
10. Right to Refuse Participation in
invasion of their privacy resulting from the
Medical Research collection, maintenance, use, and disclosure
The patient has the right to be advised if the of their personal information
health care provider plans to involve him in
medical research, including but not limited to Four main types of invasion of privacy
human experimentation which may be performed
which can lead to a civil lawsuits:
only with the written informed consent of the
1. Intrusion of solitude
patient.
● Occurs when an individual intrudes upon
another person's private affairs in physical
11. Right to Correspondence and to
manner.
Receive Visitors ● Intercepting phone calls o Peeping o Taking
The patient has the right to communicate with photographs without the knowledge of
relatives and other persons and to receive victim or consent
visitors subject to reasonable limits prescribed by ● Video recording the victim in his home
the rules and regulations of the health care without consent or knowledge
institution
2. Appropriation of name or likeness
12. Right to Express Grievances Occurs when a person's entity uses another
The patient has the right to express complaints person's name or likeness (photograph or video)
and grievances about the care and services without permission.
rendered without fear of discrimination or reprisal
and to know about the disposition of such 3. Public disclosure of private facts
complaints. Such a system shall afford all parties ● The dissemination of personal information
concerned with the opportunity to settle all that is not a public concern or interest, and
grievances amicably. that is not a part of public proceedings or
records, and which would offend any
13. Right to be Informed of His Rights reasonable person if published or widely
and Obligations as a Patient distributed.
Every patient has the right to be informed of
rights and obligations as a patient. The DOH, in 4. False light
coordination with health care provider, ● The legal doctrine of false light addresses
professionals and civic group, the media, health people's right to not have false or
insurance corporations, people's organizational, misleading information, which puts them in
local government organizations, shall launch and a false light, made public.
sustain a nationwide information and education ● It deals with the invasion of a person's
campaign to make known to people their rights privacy by disseminating false or misleading
as patient, as declared in this Act such rights and information, rather than the gathering of
obligations of patients shall be posted in bulletin information through invasion of privacy.
board conspicuously placed in health care
institution. Elements of successful claim under false light:
A. The information about the victim was
published or made public
C. Data Privacy Act B. The publication of information was made
Republic Act No. 10173 known as DATA intentionally, and with malice
PRIVACY ACT (2012) - is a law that seeks to C. The perpetrator acted with reckless
protect all forms of information, be it private, disregard for the false nature of the
personal or sensitive. It is meant to cover both information published
natural and judicial persons involved in the D. The published information puts the victim in
processing of personal Information. a false or misleading light
E. The information would be offensive or verbal communication, and
embarrassing to any reasonable person patient-centeredness. Meeting those ends is
no easy feat, especially in a traditionally
MODULE 6: HEALTH CARE TEAM IN paternalistic healthcare industry that has
long fostered power hierarchy
HEALTH ASSESSMENT
● Organizations must begin by defining the
roles of different care team members,
Team-based Approach ensuring that each individual feels valued
● Team-based care will be essential for and as though she is using her skills at the
meeting value-based care goals while also highest capacity. In recognizing the unique
delivering a positive patient experience. perspectives that each clinician brings to the
● Acknowledges that there are multiple key table, organizational leaders can begin to
players treating a patient and that each of address power hierarchies and foster a
them must work with one another in order to more egalitarian team environment
drive optimal care outcomes.
● Members of a care team may include How to implement team-based care
doctors, nurses, physician assistants, Clinician leaders should also note the role patients
specialists, and other non-clinical and their family caregivers play as members of the
professionals who are integral to caring for care team. Using shared decision-making and
a patient. patient education, clinicians can integrate patients
into treatment decisions. This will tap the patient as
"A team-based model of care strives to meet the expert on her own care and lifestyle
patient needs and preferences by actively engaging preferences that must be considered before
patients as full participants in their care, while ordering certain therapies.
encouraging all healthcare professionals to function
to the full extent of their education, certification, and How does team-based care impact the patient
experience." experience?
● Reducing health worker burnout can
Team-based care can be successful when all improve the quality of care patients receive
members are on the same page. That will because their nurses will be less tired, more
require: attuned to patient needs, and able to create
● A clear, common goal better relationships with patients
● A culture shift that facilitates teamwork ● As the healthcare industry continues to
Supportive organizational frameworks embrace value-based care, it will be
● Effective teamwork coaching essential for organizations to restructure to
meet care goals. No longer can individual
What drives the need for team-based care? clinicians go it alone. They must form
● Team-based care has become a popular relationships with their peers and establish
healthcare goal in the wake of the Industry's strong, team-based care. In doing so,
transition to value-based care models. providers can support better clinical
Given the cost-cutting and outcomes-based outcomes while supporting an overall better
goals in many value-based care models, patient experience
Industry experts assert that teamwork
between various providers is essential
● The focus on patients with chronic illness or
Role of the Nurse & Other Members
other complex health needs has also given of the Health Team
rise to the idea of team-based care. These
patients see a number of providers, Role of the Nurse
including primary care physicians, ● The professional nurse plays a vital role in
specialists, pharmacists, and the litany of the assessment of patient problems.
nurses and physician assistants who may Educational preparation and the clinical
be practicing in those facilities setting in part determine the extent to
● Teamwork between these entities increases which the nurse participates in the
the quality of healthcare, reduces repetitious assessment process.
tests, and addresses incongruities in care, ● For example, a nurse in primary care may
which can ultimately lead to better health perform a comprehensive physical
outcomes assessment of patients, while a critical
care nurse may conduct selected patient
How to implement team-based care? assessments to monitor and evaluate
● Carrying out team-based care will require a current health problems. In either case,
considerable culture shift at most healthcare nurses are expected to be familiar with
organizations. Successful team-based care and comfortable using physical
approaches promote equality between assessment skills.
different team-members, strong written and
Interprofessional Personal (Non-Nursing)
Respiratory therapist
Spiritual support staff: ● Evaluates respiratory status and provides
● Provides spiritual care (pastors, rabbis, respiratory treatments including oxygen
priests). therapy, chest physiotherapy, inhalation
● Example of when to refer: A client therapy, and mechanical ventilation.
requests communion, or the family asks ● Example of when to refer: A client who
for prayer prior to the client undergoing a has respiratory disease is short of breath
procedure. and requests a nebulizer treatment.
Registered dietitian: Radiologic technologist

● Assesses, plans for, and educates ● Positions clients and performs x-rays and
regarding nutrition needs. other imaging procedures for providers to
● Designs special diets, and supervises review for diagnosis of disorders of
meal preparation. Example of when to various body parts.
refer: A client has a low albumin level and ● Example of when to refer: A client reports
recently had an unexplained weight loss severe pain in his hip after a fall, and the
provider prescribes an x-ray of the client's
Laboratory technician hip.
● Obtains specimens of body fluids, and
performs diagnostic tests. Social worker
● Example of when to refer: A provider ● Works with clients and families by
needs to see a client's complete blood coordinating inpatient and community
count (CBC) results immediately. resources to meet psychosocial and
environmental needs that are necessary
Occupational therapist for recovery and discharge.
● Assesses and plans for clients to regain ● Example of when to refer: A client who
activities of daily living (ADL) skills, has terminal cancer wishes to go home
especially motor skills of the upper but is no longer able to perform many
extremities. ADLs. The client's partner needs medical
● Example of when to refer: A client has equipment in the home to care for the
difficulties using an eating utensil with her client
dominant hand following a surgery
Speech-language pathologist
Pharmacist ● Evaluates and makes recommendations
● Provides and monitors medication. regarding the impact of disorders or
Supervises pharmacy technicians in injuries on speech, language, and
states that allow this practice. swallowing. Teaches techniques and
● Example of when to refer: A client is exercises to improve function.
concerned about a new medication's ● Example of when to refer: A client is
interactions with any of his other having difficulty swallowing a regular diet
medications. after trauma to the head and neck
Physical therapist
MODULE 6: CORE VALUES IF
● Assesses and plans for clients to increase
musculoskeletal function, especially of the NURSING IN CONDUCTING HEALTH
lower extremities, to maintain mobility. ASSESSMENT
● Example of when to refer: Following hip
arthroplasty, a client requires assistance Values
learning to ambulate and regain strength. are enduring beliefs or attitudes about the worth of
a person, object, idea, or action. are important
Provider because they influence decisions and actions,
● Assesses, diagnoses, and treats disease including nurses' ethical decision making.
and injury. Providers include medical
doctors (MDs), doctors of osteopathy
Value systems
(DOS), advanced practice nurses (APNs),
are basic to a way of life, give direction to life, and
and physician assistants (PAs). State
form the basis of behavior- especially behavior that
regulations vary in their requirements for
is based on decisions or choices.
supervision of APNs and PAS by a
physician (MDs and DOS).
● Example of when to refer: A client has a
temperature of 39° C (102.2° F), Is achy Beliefs
and shaking, and reports feeling cold ● Or opinions
● are important because they influence
Beliefs are chosen:
decisions and actions, including nurses' ● Freely without outside pressure From
ethical decision making. alternatives
● After reflecting and considering
Attitudes consequences
● are mental positions or feelings toward a
person, object, or idea (e.g., acceptance,
Acting (Behavioral)
compassion, openness).
● are often judged as bad or good, positive or Chosen beliefs are:
negative, whereas beliefs are judged as ● Affirmed to others
correct or incorrect. ● Incorporated into one's behavior
● Repeated consistently into one's life
Values Transmission
● Values are learned through observation and
Prizing (Affective)
experience.
● Values are heavily influenced by a person's ● Chosen beliefs are prized and cherished.
socio cultural environment (traditions,
culture, ethnic, religious groups, family and
Clarifying the Nurses' Values
peers).
● Nurses and nursing students need to reflect
on the values they hold about life, death,
Personal Values health and illness.
People derive values from the society and their ● Nurses hold both personal and professional
various individual subgroups, they internalize some values.
or all of these values as personal values.
Clarifying Clients' Values
Professional Values ● Nurses should never assume that the client
Are acquired during socialization into nursing from has any particular values.
codes of ethics, nursing experiences, teachers and ● Nurses should explore clients' values
peers. through discussion.
Essential Nursing Values The following process may help clients

➤ Altruism - concern for the welfare and clarify their values:
well-being of others. 1. List alternatives.
➤ Autonomy - right to self-determination. 2. Examine possible consequences of choices.
➤ Human dignity - respect for the inherent worth 3. Choose freely.
and uniqueness of individuals and populations. 4. Feeling about the choice.
➤ Integrity - acting in accordance with appropriate 5. Affirm the choice.
code of ethics and accepted standards of practice. 6. Act with a pattern.
➤ Social justice - Acting in accordance with fair
treatment regardless of economic status, race,
ethnicity, age, citizenship, disability, or sexual
orientation
Values Classification
● Process by which people identify, examine
and develop their own individual values.
● Principle: No one set of values is right for
everyone.
● Promotes personal growth by fostering
awareness, empathy and insight.
● Raths, Harmin and Simon (1978) developed
the theory of values clarification that was
widely used. They described a "valuing
process" of thinking, feeling and behavior,
termed them as "choosing", "prizing" and
"acting"
Choosing (Cognitive)

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UNIT 5A: Physical Assessment

A. Skin, Hair and Nails

A. Skin, Hair, and Nails Assessment

B. Equipment Used for EXAMINATION OF THE SKIN

C. Examination and Findings

● Cyanosis may cause white skin to appear

● is roughening and darkening of skin in

● A strong odor of perspiration or foul odor may

Erythema (skin redness and warmth) is seen in

Check skin integrity, especially carefully in pressure point areas.

● Skin is smooth and even. ● Rough, flaky, dry skin is seen in

● Skin is normally a warm temperature ● Cold skin (shock or hypotension)

Palpate to assess mobility and turgor.

● Natural hair color ● Nutritional deficiencies may cause patchy

LYMPH NODES OF THE HEAD AND NECK

EQUIPMENT BEING USED:

C. Examination and Findings

Inspection and Palpation

An involuntary nodding movement (aortic

Head tilted to one side (unilateral vision/ hearing

Palpate the head. Palpate for consistency

● No swelling, tenderness, or crepitation with ● Limited ROM, swelling, tenderness, or

● No bruits are auscultated ● A soft, blowing, swishing sound auscultated

Lymph Nodes of the Head and Neck

No swelling or enlargement, no tenderness, no Enlarged nodes are abnormal.

The middle layer contains both an anterior

The innermost layer, the retina, extends only to

Visual Fields and Visual Pathways

C. Examination and Findings

Test near visual acuity.

Test visual fields for gross peripheral vision

● Normal visual field degrees are approximately

Testing Extraocular Muscle Function

Perform cover test.

● Nystagmus, an oscillating (shaking)-

Inspection and Palpation

Observe redness, swelling, discharge. Or lesions.

● Skin on both eyelids is without redness, ● Seborrhea or blepharitis- Redness and

Inspect the bulbar conjunctiva and sclera

● Clear, moist, and smooth ● conjunctivitis (pink eye).

Inspect the palpebral conjunctiva

Inspect and palpate the lacrimal apparatus.

Inspect the cornea and lens

● transparent with no opacities. ● Areas of roughness or dryness (injury or

Inspect the iris and pupil

● normal direct pupillary response is ● Monocular blindness -no response in either

Test accommodation of pupils

The normal pupillary response is constriction of the ● Pupils do not constrict

C. Examination and Findings

Normal Findings Abnormal Findings

● Tenderness over the mastoid process

● Tenderness behind the ear may occur

● With sensorineural hearing loss, the client

Other terms used to document Cardiac Cycle and Heart Sounds

Can be visible just medial to the left

ABNORMAL FINDINGS Breast and Lymphatic System

Arms at the side ● Circular pattern

Symmetry EXPECTED FINDINGS

Note any guarding or splinting of the abdomen. •

ASSESS THE SKIN FOR: